Provider Demographics
NPI:1720738099
Name:BROOM, CODY O'NEAL
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:O'NEAL
Last Name:BROOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:599C STEED RD
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-1707
Mailing Address - Country:US
Mailing Address - Phone:601-605-6777
Mailing Address - Fax:
Practice Address - Street 1:11 PECAN DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-2600
Practice Address - Country:US
Practice Address - Phone:601-731-5717
Practice Address - Fax:601-633-0082
Is Sole Proprietor?:No
Enumeration Date:2022-03-28
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA7008225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant